Technical Considerations in Pedicle Management in Upper and Midfacial Free Flap Reconstruction

Abstract

Objectives: Mid and upper face free flaps frequently are associated with challenges due to pedicle length. We sought to evaluate the frequency at which alternative pedicle maneuvers were required for these reconstructions and determine if there was any association with flap survival or postoperative complications.Study Design: Retrospective review at three tertiary care institutions. Methods: Database review.Results: Free flap reconstruction of the upper and midface was performed in 295 patients (108 bony, 187 soft tissue). In 82% of cases, the vessels reached the ipsilateral neck for anastomosis to traditional target vessels. Arterial grafts were required in 2% of reconstructions (4% bony and 1% soft tissue). Venous grafting was required in 7% of reconstructions (21% fibula, 16% scapula, and 3% soft tissue) and was associated with an increase in flap failure rate (19% vs 3%, P = .003). The most common recipient artery for revascularization was the cervical facial artery (78%). Alternate recipient vessels were selected in 13% of cases, including the superficial temporal vessels (7%), distal facial branches through a separate facial incision (4%), and angular vessels (2%). Vein grafting was associated with a higher flap failure rate. Alternative maneuvers did not affect need for intraoperative pedicle revision or complications.Conclusions: In upper and midface reconstruction, vascular grafting, targeting more distal branches of the facial system, or additional maneuvers to optimize pedicle orientation is often required to secure revascularization. Vein grafting is associated with a higher free flap failure rate. Scapular border flaps often require vascular grafting or atypical anastomotic locations.

Comparisons of Impact of Vein Grafting with Different Indications on Outcomes of Reconstruction with Free Flaps

“…21,24,26 Later studies disagree regarding influence of vein grafting on flap survival. Kapila et al and Swendseid et al 7,38 found that vein grafts were associated with higher rates of flap failure or takebacks, whereas Di Taranto et al and Lai et al 16,29 found that vein grafts were not associated with higher risk of flap failure. This study shows vein grafts used in the primary operation to lengthen the pedicle were not associated with flap failure.…”

“…Microsurgical outcomes after use of a vein graft have been analyzed in literature by vein graft type, 5 8 20 21 22 23 24 25 26 27 28 vein graft length, 29 30 31 vein graft donor site, 32 33 34 flap donor and recipient sites, 11 20 24 35 36 37 38 or the indication for reconstruction, 8 19 22 but few studies have examined vein graft outcomes by vein graft indication. 39 Flaps requiring a vein graft for salvage of a compromised flap are completely different from flaps needing a vein graft to increase pedicle length.…”